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Patients with HCC more likely to be placed on liver transplant waitlists

Patients with hepatocellular carcinoma were more likely to be placed on liver transplant waitlists than other patients with end-stage liver disease, according to recent findings published in Clinical Gastroenterology and Hepatology.

“We consistently demonstrate significantly higher rates of waitlisting for patients with HCC, independent of cirrhosis stage and other comorbidities,” David Goldberg, MD, in the division of gastroenterology at the University of Pennsylvania Perelman School of Medicine, and colleagues wrote. “The development of HCC greatly increases the probability that a patient with cirrhosis will be waitlisted for a liver transplant.”

David Goldberg

Transplant centers use a ‘sickest-first’ model to determine who receives a liver transplant, but patients are also evaluated by post-transplant outcomes, the researchers wrote. As a result, transplant physicians must balance between prioritizing the sickest patients and maximizing post-transplant survival.

To evaluate factors associated with waitlisting among patients with ESLD, Goldberg and colleagues performed a retrospective study of data from HealthCore Integrated Research Database between 2006 and 2014 (n = 16,824) as well as Medicaid data from California, Florida, New York, Ohio and Pennsylvania between 2002 and 2009 (n = 67,706). Patients were considered eligible for a transplant if they had decompensated cirrhosis, HCC or liver synthetic dysfunction. The researchers used the Organ Procurement and Transplantation Network Database to determine which patients were placed on the transplant waitlist.

In the HealthCore database, 29% of patients with HCC (95% CI, 25.4-33) were placed on the 2-year waitlist compared with 11.9% of patients with stage 4 cirrhosis. (95% CI, 11-12.9) and 12.6% of patients with stage 5 cirrhosis (95% CI, 9.4-15.2). Among patients with each stage of cirrhosis, those with HCC were significantly more likely to be placed on the waitlist. The adjusted sub-hazard ratio ranged from 1.7 for patients with stage 5 cirrhosis to 5.8 for patients with stage 1 cirrhosis. For patients in the Medicaid database, patients with HCC were also more likely to be placed on the waitlist (HR = 2.34; 95% CI, 2.2-2.49). Further, local organ supply and waitlist level demand were not associated with waitlist placement.

These data suggest that patients with HCC are more likely to be placed on the waitlist, but they do not suggest why, the researchers wrote.

“Further work is needed to determine whether these differences are attributable to variable referral practices at the level of the primary physician caring for these patients, or differences in decision making at the level of the liver transplant center,” Goldberg and colleagues wrote. “Nevertheless, the dramatic differences in waitlisting for patients with HCC, who are already at a significant advantage once waitlisted, raises the question of whether allocation policies need to consider not simply the impact to patients on the waitlist, but also patients who may be referred or evaluated for transplantation.” – by Will Offit

Disclosure: The researchers report no relevant financial disclosures.